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Upswing Health

INFORMED CONSENT FOR TELEMEDICINE SERVICES

Telemedicine is a tool used by the health care providers of Upswing Health to diagnose, consult, treat and educate patients remotely using telecommunications technologies, such as video conferencing or telephone.

Expected benefits of telemedicine:

  • Easier access to care
  • Potential cost savings

Possible limitations of telemedicine:

  • Telemedicine sessions could be disrupted or distorted by technical failures
  • Lack of face to face and hands-on examination means that telemedicine treatment is different from and can sometimes be more limited than in-person medical services
  • Lack of access to a complete medical record could affect treatment results

By providing my electronic signature below, I hereby consent to receiving health services via telemedicine, rather than in-person, under the terms and conditions set forth below:

  1. Telemedicine services will be provided to me when it is determined to be appropriate by Upswing Health.
  2. I understand there are potential benefits and risks to telemedicine services.
  3. I understand that it is my responsibility to provide my telemedicine provider with detailed, accurate and complete information concerning my medications, medical history, and current symptoms.
  4. I understand that Upswing Health is not responsible for any technological problems over which Upswing Health has no control. I further understand that Upswing Health does not guarantee that technology will be available or work as expected.
  5. I understand that I am responsible for information security on my device, including but not limited to, computer, tablet, or phone, and at my location.
  6. I understand that I have a right to confidentiality regarding my telemedicine treatment under the same laws that protect the confidentiality of my medical information for in-person medical services. However, I understand that there are, by law, exceptions to confidentiality, including, but not limited to, mandatory reporting of abuse.
  7. I understand that an alternative to receiving telemedicine services is to receive in-person services through another health care provider.
  8. Upswing Health will not record your telemedicine sessions. I understand that I may not record any telemedicine sessions without written consent from Upswing Health.
  9. I acknowledge that telemedicine through Upswing Health is NOT an emergency service. In the event of an emergency, I will call 911 and/or other appropriate emergency contacts.
  10. I have read and understand the information provided above. I have the right to discuss any of this information with my telemedicine provider and to have any questions I may have regarding my treatment answered to my satisfaction.
  11. I understand that I can withdraw my consent to telemedicine services by providing written notification to Upswing Health. My electronic signature below indicates that I have read this Informed Consent form, agree to its terms and thus consent to receiving telemedicine services.
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